Integrating Mutational Analysis Into the Clinical Management of Patients With Myelofibrosis
June 12, 2018 10:28pm
By Douglas Tremblay, MD
The NCCN published its first set of guidelines for myeloproliferative neoplasms in October 2016 and is already looking to update and expand these guidelines to match the need for direction in diagnosing and treating patients with MPNs.
Ruben A. Mesa, MD
The National Comprehensive Cancer Network (NCCN) published its first set of guidelines for myeloproliferative neoplasms (MPNs) in October 2016 and is already looking to update and expand these guidelines to match the need for direction in diagnosing and treating patients with MPNs.
The guidelines initially focused on diagnosing each of the MPNs and treatment options for patients with myelofibrosis, as that was the disease type with the greatest unmet need, Ruben A. Mesa, MD, explained in an interview withTargeted Therapies in OncologyTMfollowing his presentation at the 2017 NCCN Annual Conference.
“The myeloproliferative neoplasms were probably one of the most significant of the hematologic malignancies that did not yet have NCCN guidelines,” said Mesa, a professor of medicine and chair of hematology at Mayo Clinic in Phoenix, Arizona, and chair of the panel for the NCCN guidelines on MPNs. “The guidelines are very helpful in terms of improving quality of care by providing more homogeneity of care in the United States, trying to bring in current evidence regarding treatment that can be utilized, as well as clarifying the role of a variety of things, ranging from transplantation to therapies.”
The guidelines look to explain the criteria for diagnosing each of the MPNs, including the World Health Organization’s recent update to the classi cation of MPNs, and risk assessment. Yet the current edition of the guidelines only included treatment options for patients with myelofibrosis. Treatment guidelines for patients with polycythemia vera or essential thrombocythemia are expected in the update, which Mesa remarked is expected in the summer of this year.
The myelofibrosis guidelines incorporate scoring systems for risk stratification, including the International Prognostic Scoring System (IPSS), the Dynamic IPSS (DIPSS), and the DIPSS-Plus. Mesa also noted that the guidelines endorse the 2013 International Working Group for Myelofibrosis Research and Treatment and European LeukemiaNet consensus response criteria, as well as the scoring system for total symptom burden.
“In myelofibrosis, there are clinical improvement criteria that can stand alone. You can have reduction in splenomegaly that counts as a response. What that leads to for clinical decision making is more subtle, and like all of these guidelines, they are married to clinical experience and expertise in terms of the character of response and how that balances against any negatives that come with the treatment in terms of side effects or toxicities as well as expense,” he said.
The guidelines also describe the prognostic significance of several common mutations in patients with primary myelofibrosis. Patients with anMPLW515L/K mutation, for example, have a higher risk of thrombosis compared with patients who have aCALRmutation, and they usually have an intermediate prognosis. Those who do not haveJAK2,MPL, orCALRmutations have an inferior prognosis compared with patients with these driver mutations, with lower leukemia-free and overall survival rates. Patients withTP53mutations are associated with a greater risk for transformation to acute myeloid leukemia.
For patients with low-risk asymptomatic myelofibrosis, the guidelines recommend either observation for signs and symptoms of disease progression or a clinical trial. For symptomatic patients who are low risk, the guidelines suggest interferons, a clinical trial, or ruxolitinib (Jakafi), the only FDA-approved targeted agent for patients with myelofibrosis. Ruxolitinib, a JAK1/2 inhibitor, is also recommended for patients with intermediate-1 and -2 disease, especially for those with intermediate-2 disease who are not candidates for transplant and have a high platelet count.
“Ruxolitinib is the only FDA-approved therapy, so obviously it leaves you somewhat challenged when you fail that therapy,” Mesa said. “That’s the greatest unmet need, and certainly many of the current clinical trials are aimed at trying to assist patients that have ‘failed ruxolitinib.’”
Although the guidelines do consider some options for when a patient is ruxolitinib intolerant or resistant, including agents such as udarabine and busulfan, they strongly encourage clinical trials. However, he noted that the expected updates to the MPN guidelines will delve further into more options for patients following progression on ruxolitinib.
In his presentation, Mesa also addressed several promising second-line agents currently in development, including pacritinib, momelotinib, imetelstat, and PRM-151. “We’ve seen data recently that certainly was encouraging. Although neither agent is approved yet, both pacritinib and momelotinib had beneficial data in that second-line setting. Data from 2 clinical trials are eagerly anticipated for PRM-151, the antifibrosing agent, as well as imetelstat. Those are 2 second-lines studies that are of great interest. We desperately need other agents approved because we only have 1 approved drug, [and that is] ruxolitinib. If a second drug becomes approved, we will undoubtedly work to revise the guidelines in a very rapid fashion to provide clarity and situational use,” Mesa continued.
He remarked that the guidelines are a starting point for oncologists who are less familiar with diagnosing and treating patients with these diseases. However, the experience of oncologists more familiar with MPNs could outweigh the recommendations in the guidelines. “We’re hopeful that [the guidelines] will be a good resource for community oncologists in clarifying a range of issues with these diseases,” Mesa concluded. “How one walks that path, there’s a lot of individual factors and clinical experience that are highly relevant.”
NCCN. NCCN clinical practice guidelines in oncology (NCCN guidelines): myeloproliferative neo- plasms. Version 2.2017. National Comprehensive Cancer Network website. https://www.nccn.org/ professionals/physician_gls/pdf/mpn.pdf. Published October 19, 2016. Accessed March 25, 2017.